A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?
Document the infiltration.
Stop the infusion.
Elevate the arm.
Apply a warm compress.
The Correct Answer is B
The correct answer is B.
Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action according to the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Hypertension. The rationale is that oral contraceptives contain synthetic hormones that can increase blood pressure and increase the risk of
cardiovascular events such as stroke, heart attack or blood clots. The nurse should advise the client to avoid oral contraceptives if she has hypertension or other risk factors for cardiovascular disease and suggest alternative methods of birth control.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is Choices A, C, and D.
Choice A rationale:
The statement, "I should avoid douching or using tampons for 24 hours after the Pap smear," demonstrates an understanding of post-procedure instructions. It reflects awareness of the need to avoid introducing foreign substances into the vagina immediately after the procedure, which could interfere with the accuracy of the results or increase the risk of infection. By abstaining from douching or tampon use, the client follows recommended guidelines for post-Pap smear care, promoting optimal healing and accuracy of results.
Choice B rationale:
The statement, "I can resume sexual activity as soon as I leave the clinic," is incorrect and does not reflect an understanding of post-Pap smear instructions. Resuming sexual activity immediately after the procedure is not recommended, as it may increase the risk of infection or discomfort. The client should be advised to abstain from sexual activity for a specified period, typically recommended by the healthcare provider, to allow for proper healing and to minimize the risk of complications.
Choice C rationale:
The statement, "It’s normal to experience some mild cramping or spotting after the procedure," demonstrates an understanding of common post-Pap smear symptoms. Mild cramping and spotting are normal reactions to the procedure and are not typically indicative of a problem. By acknowledging these potential side effects, the client shows awareness of what to expect after the Pap smear and is better prepared to manage any discomfort that may arise.
Choice D rationale:
The statement, "I should call the clinic if I experience heavy bleeding or foul-smelling discharge," reflects an understanding of the importance of monitoring for signs of complications post-procedure. Heavy bleeding or foul-smelling discharge may indicate an infection or other issues that require prompt medical attention. By instructing the client to contact the clinic in such situations, the nurse ensures that the client knows how to respond appropriately to potential complications, promoting their overall well-being and timely intervention if necessary.
Choice E rationale:
The statement, "I can expect the results of my Pap smear in about 2-3 days," is incorrect and does not reflect an understanding of the typical timeline for receiving Pap smear results. Pap smear results usually take longer, often a week or more, to be processed and interpreted by the laboratory. Providing accurate information about result expectations is essential for managing the client's post-procedure anxiety and ensuring realistic expectations regarding follow-up.
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